Low Vision Services Referral Form

To refer a patient to our Low Vision Services, please complete the following referral form. We will contact your patient promptly to schedule an appointment, and following services, you will receive a status report for your records.

"*" indicates required fields

Patient Information

MM slash DD slash YYYY

Parent/Guardian Information: Complete only if patient is under 18

Referring Physician's Information

MM slash DD slash YYYY
MM slash DD slash YYYY

Restricted Peripheral Vision?

Restricted Peripheral Vision OD*
Restricted Peripheral Vision OS*

Positive Amsler?

Positive Amsler OD*
Positive Amsler OS*


Pseudophakia OD*
Pseudophakia OS*